What are the guidelines for performing and managing a tracheostomy?

Guidelines for Performing and Managing a Tracheostomy

Proper tracheostomy management requires standardized protocols, appropriate equipment, and trained personnel to minimize complications and prevent mortality from airway emergencies.

Types and Indications

Tracheostomies can be temporary or permanent and are performed using either:

• Open surgical technique
• Percutaneous dilatational technique (PDT)

Common indications include:

• Management of upper airway obstruction
• Airway protection
• Facilitation of weaning from mechanical ventilation
• Long-term ventilation
• Assistance with respiratory secretion removal 1

Equipment Requirements

Essential Bedside Equipment

• Spare tracheostomy tubes (same size and one size smaller)
• Spare inner tubes
• Functional suction equipment with appropriate catheters
• Oxygen source
• Manual resuscitation bag
• Waveform capnography (mandatory for ventilated patients)
• Tracheostomy emergency kit 1, 2

Performing a Tracheostomy

Timing Considerations

Based on recent evidence, it is reasonable to wait at least 10 days to confirm ongoing mechanical ventilation need before considering tracheostomy 3.

Technique Selection

• Percutaneous dilatational tracheostomy (PDT) is recommended with flexible bronchoscopy guidance
• PDT advantages include:
  • Shorter procedure time
  • Lower cost ($1753 vs $2604 for surgical approach)
  • Can be performed at bedside 4
• Surgical tracheostomy may be preferred for:
  • Patients with difficult neck anatomy
  • Emergency situations
  • When bronchoscopy is unavailable 3

Managing Tracheostomy Emergencies

Emergency Algorithm for Tracheostomy Problems

1. CALL FOR HELP - Activate emergency response
2. Apply oxygen to face AND stoma
3. Assess patency:
   • Look for breathing
   • Remove speaking valves/caps
   • Remove inner tube if present
   • Attempt to pass suction catheter
4. If blocked:
   • Deflate cuff if present
   • Try to replace tube with same or smaller size
   • Limit to three attempts at reinsertion 1

Primary Emergency Oxygenation

If tube cannot be replaced or is non-functional:

• For patients with patent upper airways: use standard airway management (bag-valve mask, oral/nasal airways, supraglottic devices)
• For patients with obstructed upper airways: ventilate via stoma using pediatric facemask or laryngeal mask applied over stoma 1

Secondary Emergency Oxygenation

If primary measures fail:

• Attempt oral intubation with a long (uncut) tube advanced beyond the stoma
• Consider stoma intubation with smaller tracheostomy tube or tracheal tube
• Use fiberoptic scope guidance when available 1

Special Considerations for Laryngectomy Patients

Laryngectomy patients:

• Have no connection between upper airway and lungs
• Usually do not have tracheostomy tubes in place
• May have tracheo-esophageal puncture (TEP) valves that should not be removed
• Do not require upper airway management
• Can be ventilated directly through stoma 1

Complication Prevention and Management

Common Complications

• Immediate: hemorrhage, loss of airway
• Short-term: tube blockage, displacement
• Long-term: tracheomalacia, tracheal stenosis, stoma problems 1

Critical Safety Measures

• Waveform capnography is essential - NAP4 study reported 50% of airway-related deaths in critical care were associated with tracheostomy displacement, and capnography could have prevented >80% of these deaths 1
• All ventilated tracheostomy patients should have continuous waveform capnography monitoring
• Standardized protocols for tracheostomy insertion and care improve outcomes 3

Multidisciplinary Approach

Effective tracheostomy management requires:

• Standardized protocols
• Dedicated tracheostomy teams
• Regular staff education
• Clear emergency algorithms
• Appropriate equipment availability 1, 3

Implementing these guidelines can significantly reduce morbidity and mortality associated with tracheostomy complications and emergencies.